Health Status Questionnaire (HSQ) for PLCO

Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial (PLCO) (NCI)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0407 can be found here:

Documents and Forms

Document Name Document Type
Form 3A Health Status Questionnaire (HSQ) for PLCO Form and Instruction
3A Health Status Questionnaire (Male-HSQ) Attach_03A_HSQ-Male9_24_12.doc Form and Instruction
3B Health Status Questionnaire (Female-HSQ) Attach_03B_HSQ-Female9_24_12.doc Form and Instruction

Information Collection (IC) Details

IC Title:	Health Status Questionnaire (HSQ) for PLCO	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	3A	Health Status Questionnaire (Male-HSQ)	Attach_03A_HSQ-Male9_24_12.doc		No	No	Printable Only
Form and Instruction	3B	Health Status Questionnaire (Female-HSQ)	Attach_03B_HSQ-Female9_24_12.doc		No	No	Printable Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title: 09-25-0200, "Clinical, Basic and Population-based Research Studies of the National Institutes of Health (NIH), HHS/NIH/OD"	FR Citation: 67 FR 60776

Number of Respondents: 2,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	2,000	2,000
Annual IC Time Burden (Hours)	167	167
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.